<!DOCTYPE html>
<html lang="zh" xmlns:th="http://www.thymeleaf.org" >
<head>
    <th:block th:include="include :: header('新增出院结算')" />
    <th:block th:include="include :: datetimepicker-css" />
</head>
<body class="white-bg">
    <div class="wrapper wrapper-content animated fadeInRight ibox-content">
        <form class="form-horizontal m" id="form-leaveHosPay-add">
            <div class="form-group">    
                <label class="col-sm-3 control-label">app_id：</label>
                <div class="col-sm-8">
                    <input name="appId" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">用户名：</label>
                <div class="col-sm-8">
                    <input name="synUserName" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">效验码：</label>
                <div class="col-sm-8">
                    <input name="synKey" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label is-required">住院号：</label>
                <div class="col-sm-8">
                    <input name="inHosNo" class="form-control" type="text" required>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付类型：</label>
                <div class="col-sm-8">
                    <select name="payType" class="form-control m-b" th:with="type=${@dict.getType('his_pay_type')}" required>
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付交易流水号：</label>
                <div class="col-sm-8">
                    <input name="payRecord" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label is-required">支付金额：</label>
                <div class="col-sm-8">
                    <input name="payMoney" class="form-control" type="text" required>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label is-required">医保统筹金额：</label>
                <div class="col-sm-8">
                    <input name="overMoney" class="form-control" type="text" required>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">社保卡号：</label>
                <div class="col-sm-8">
                    <input name="socialsecurityNO" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">医保卡类型：</label>
                <div class="col-sm-8">
                    <select name="medicareType" class="form-control m-b" th:with="type=${@dict.getType('his_medicare_type')}">
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">医保返回信息：</label>
                <div class="col-sm-8">
                    <input name="medicareReturn" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">创建时间：</label>
                <div class="col-sm-8">
                    <div class="input-group date">
                        <input name="creatTime" class="form-control" placeholder="yyyy-MM-dd" type="text">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                    </div>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付状态：</label>
                <div class="col-sm-8">
                    <input name="successfulPayment" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付交易流水号：</label>
                <div class="col-sm-8">
                    <input name="outTradeNo" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">微信订单号：</label>
                <div class="col-sm-8">
                    <input name="transactionId" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">银行返回信息：</label>
                <div class="col-sm-8">
                    <input name="bankReturn" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">医院出院流水号：</label>
                <div class="col-sm-8">
                    <input name="clearingNo" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">患者姓名：</label>
                <div class="col-sm-8">
                    <input name="patientName" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">患者性别：</label>
                <div class="col-sm-8">
                    <select name="patientSex" class="form-control m-b" th:with="type=${@dict.getType('sys_user_sex')}">
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">住院日期：</label>
                <div class="col-sm-8">
                    <div class="input-group date">
                        <input name="inHosDate" class="form-control" placeholder="yyyy-MM-dd" type="text">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                    </div>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">住院状态：</label>
                <div class="col-sm-8">
                    <select name="inHosState" class="form-control m-b" th:with="type=${@dict.getType('his_inHos_state')}">
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">床号：</label>
                <div class="col-sm-8">
                    <input name="bedNo" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">科室编码：</label>
                <div class="col-sm-8">
                    <input name="departmentOrganId" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">科室名称：</label>
                <div class="col-sm-8">
                    <input name="departmentName" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">出院温馨提醒：</label>
                <div class="col-sm-8">
                    <input name="reminder" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">his接口返回信息：</label>
                <div class="col-sm-8">
                    <input name="resultMsg" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">his接口返回信息：</label>
                <div class="col-sm-8">
                    <input name="resultCode" class="form-control" type="text">
                </div>
            </div>
        </form>
    </div>
    <th:block th:include="include :: footer" />
    <th:block th:include="include :: datetimepicker-js" />
    <script th:inline="javascript">
        var prefix = ctx + "his/leaveHosPay"
        $("#form-leaveHosPay-add").validate({
            focusCleanup: true
        });

        function submitHandler() {
            if ($.validate.form()) {
                $.operate.save(prefix + "/add", $('#form-leaveHosPay-add').serialize());
            }
        }

        $("input[name='creatTime']").datetimepicker({
            format: "yyyy-mm-dd",
            minView: "month",
            autoclose: true
        });

        $("input[name='inHosDate']").datetimepicker({
            format: "yyyy-mm-dd",
            minView: "month",
            autoclose: true
        });
    </script>
</body>
</html>